Healthcare Provider Details

I. General information

NPI: 1114440179
Provider Name (Legal Business Name): KEITH SAMUEL BASS NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 N MAIN ST
ANNA IL
62906-1668
US

IV. Provider business mailing address

20 LYNWOOD LN
ANNA IL
62906-3265
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-4471
  • Fax:
Mailing address:
  • Phone: 217-898-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015848
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277002840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: